Swanton House Care Centre Also known as 1-126608129

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment we rated this key question as requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We have identified a breach of regulation in relation to safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider mostly had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety but communication across the whole home required some improvement and effective actions were not always taken by staff. Evidence was provided of lessons learnt following incidents and systems were improving to continually identify and embed good practice.

Following recent incidents the registered manager provided evidence of ongoing learning and support for staff to reduce the likelihood of further incidents. Whilst this learning was robust we found some staff told us debriefs after incidents did occur, but these were informal and often included in handover at the start or at the end of the shift. At the time of our assessment senior management met once a week to discuss the individual units. We questioned the frequency of these meeting due to the complexities across the different units and the need to ensure that risks were properly recorded and managed and lessons learnt across the entire site. Giving that it was such a large staff team and team meetings were poorly attended we felt that communication at the top of the service needed to be more robust. Since providing our feedback during the assessment the registered manager introduced head of department daily meetings to focus on risk .

Whilst on site we observed some people shouting at each other which we felt staff intervention would have been helpful in preventing further escalation. Several care plans lacked clear guidance about the potential risks of negative behaviours on individuals or other people using the service. Staff spoken with knew people well and saw some behaviours as the norm for that person so did not always understand the potential risk of when to raise a concern. For example a number of people had sexualised behaviours ( aimed at staff ) and could have placed people and, or staff in a vulnerable situation. Risk assessments and positive sexuality plans were not in place and would have ensured staff knew how to support people to express their sexuality in a positive way, within appropriate boundaries.

The provider mostly worked well with people and healthcare partners to establish and maintain safe systems of care. They mostly ensured there was continuity of care, including for when people moved between different services. However this was compromised by records not always being up to date.

Hospital passports did not always clearly communicate to other health care providers the person’s main health care needs, prescribed medications and risks associated with their care.

This could compromise the needs of people using the service particularly when transferring to a different setting. We asked if people were escorted to the hospital and this was not always the case so hospital staff were reliant on information about the person being accurate.

Since our assessment we have been assured by the provider that hospital passports have been updated. Care records required improvement to ensure that health care advice was properly recorded to show how it had been acted upon and care plans and risk assessments updated.

We spoke to a number of health care professionals who told us they were made welcome at the service and there were good lines of communication and staff were familiar with people’s needs and felt that the staff made appropriate referrals.We however identified areas of concern which had not been referred.

The provider did not always ensure safeguarding procedures were followed. Staff had not always escalated incidents of concern to managers or relevant external professionals. This meant people were at increased risk of harm.

Governance systems were not sufficiently robust, and we identified incidents which had not been recorded or escalated to ensure people were properly safeguarded.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Risks to people’s safety and well-being were not always effectively assessed to ensure changing needs and risks could be quickly identified and where possible reduced. The recording and escalation of risk required improvement. Risk assessments were not always up to date or cross referenced with other records.

Planned actions to monitor people with epilepsy did not fully mitigate the risks associated with seizures. People with a speech and language therapy plan (SALT) had been reviewed prior to our assessment following a choking incident. We found however during our assessment some people were left unsupervised whilst eating or eating in a poor position. A person’s hospital passport for someone recently in hospital did not make it clear what their eating risks were. Staff had not always made referrals to specialist professionals, such as the learning disability team and epilepsy team.

Actions to address risks in relation to behaviour that may challenge and for off-site activities were not sufficiently robust.

People experienced gaps in their care in relation to ‘Right support, Right care Right culture’ but we found the registered manager to be responsive to our feedback.

Fire safety had been considered with comprehensive risk assessments and fire drills. However, we found individual PEEPS, (Personal emergency evacuation plans) were limited in detail and did not assure us staff would know how to support people correctly in an emergency.We shared our concerns with the registered manager who started to take action to improve risk management plans following our visits to the service.

The continuity of staff helped to mitigate some risk because staff knew people’s needs well.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were potential ligature risks on Holly Court and ligature incidents which had not been reported. Some areas of the service had more limited space which restricted the types of needs that could be met in those areas. Uneven flooring at Birch House was noted this could present a risk to people with poor mobility or sensory issues and no signage was in place. Whilst risks were identified the registered manager was responsive to feedback and took immediate steps to lessen risks.

We noted records were not always updated to show when health and social care professionals had made recommendations about equipment. The provider when considering epilepsy monitoring alarms had not recorded other options considered to ensure which option was the most effective and least restrictive. This was addressed during our assessment.

Overall, we found the environment and individual units were well managed with robust estates management and effective cleaning schedules. One relative told us,” The maintenance is very pro-active, and re-painting has just been completed.” Additionally, relatives told us there was security on the individual units and key fobs, door alarms and individual alarms.

The provider made sure there were enough qualified, skilled, and experienced staff. Staff received effective support, supervisions and development. They worked well together to provide safe care that met people’s individual needs.

Some people had assigned individual staff support (1-1) hours. Other people had shared support. This enabled some people more opportunity to go out individually. Staffing levels were determined by people’s assessed level of needs and how many staff were deemed appropriate to support them. Whilst staffing levels were mostly maintained and staff retention was good the occasional short term and long-term sickness impacted on the service. The registered manager told us however there were additional staff across the day who were not rostered on shift and could step in to support care staff when necessary. Temporary agency staff were hardly ever necessary which meant people were regularly supported by staff familiar with their needs. Staff did not raise significant concerns about staffing levels. However, some staff said they could be short staffed especially on Holly Court. A relative told us,” “There never seems to be enough staff but that might be me repeating what you read and hear about. There is a core staff of 6-8 people who we see regularly and have seen a couple of new ones recently. The staff appear to be well trained and are helpful and we have no issues with them.”

Effective systems were in place to regularly monitor staffs’ practices within the workplace to ensure staff were reducing the risk of cross infection in line with policies and procedures.

No concerns were identified as part of our assessment around hygiene practices, premises were clean, and the kitchen had been recently awarded 5 stars. Relatives commented on hygiene standards., One told us, “Yes, the home is very well cleaned and maintained.”

Staff were observed wearing personal protective clothing (PPE) when required. Minutes of audits identified when cleaning standards fell below an expected standard, and this was addressed quickly. Equipment was in good working order and checks were carried out on mattresses etc to ensure they were sufficiently clean and sterile.

The service made sure medicines and treatments were safe and met people’s needs. Systems and processes identified and mitigated risks associated with medicines.

During our assessment we found no concerns other than concerns already identified by the provider which were being addressed. There were safe systems in place to order, manage and administer medicine. We found however clear guidance was not always in place when people required medicines occasionally and when these should be administered. Nurses and team leaders were fully trained to give medicines, and all care staff were trained to understand medicine groups and what potential side effects to look out for. We had concerns that some important information like about people’s allergies and, or anticoagulant medicines were recorded on the medication administration records but not included in other care records. We discussed this with the registered manager who took action to rectify this.

The GP and other mental health team specialists advised us that medicine reviews were up to date and where possible medicines were reduced in line with STOMP (Stopping over medication of people with a learning disability, autism, or both).